Let's Treat Housing as a Health Issue

A tuberculosis test being administered. While TB is largely a disease of the past for Americans, it still occurs with some regularity among homeless people.

Governor Andrew Cuomo and New York State did something recently that homeless advocates in New York City have long argued for. They adopted the policy that housing is health care.

Health care professionals who specialize in treating people experiencing homelessness have known it, and said it, for a long time. It's not just easier to access treatment when you're stably housed, but ongoing treatment is always more effective for those who have stable housing.

As early as 1998, The New England Journal of Medicine published a study, based on New York City data from over 400,000 hospital discharges, that conclusively labeled homelessness as an extraordinarily aggravating condition for numerous chronic conditions and showed it produced "substantial excess costs" both in preventable utilization of emergency rooms and hospitals and in longer and more expensive hospital stays.

The study recommended more "low-cost housing," supportive housing and better access to substance abuse treatment programs as prescriptions for "a more cost-effective as well as more humane approach to the problem of homelessness."

Since then there have been a dozen more academic studies all showing the same thing. Homelessness itself aggravates chronic health conditions, interferes with the effectiveness of treatment and drastically increases emergency room visits and length of hospital admissions.

Study after study also documents that housing instability aggravates rates of morbidity (a measure of poor health) and increases age adjusted mortality rates (a measure of early deaths). People who experience significant periods of homelessness have a much shorter life expectancy. One study documented a 36 percent reduction in life span.

Many studies show age adjusted life expectancy for chronically homeless people is in the 40s and 50s, compared to a national life expectancy of over 80 years (a male child born today in the U.S. has a life expectancy of 82.8 years; it's 86.7 for a female). A 2012 study published in the International Journal of Epidemiology concluded "homelessness is an independent risk factor for death from specific causes."

Homelessness itself is a contributing cause of ill health and premature deaths.

Chronic homelessness disrupts the effectiveness of ongoing medical care. Statistically homelessness has a strong correlation with certain illnesses which occur with much greater frequency in homeless people than others. Homeless people suffer in tremendously greater proportion from major depression and mental illness, pulmonary disease, circulatory maladies, respiratory problems, liver disease, diabetes, hypertension, HIV/AIDS and sexually transmitted diseases, asthma, hepatitis and many other conditions.

Tuberculosis, almost wiped out for a period in America, still occurs with some regularity among homeless people. They experience incidents of traumas, infections and extreme stress at far greater frequencies than the general population.

Managing treatment on the streets, or even in shelters, is difficult. Fighting infections with an already compromised or weak immune system in close living conditions or with constant exposure to the elements can be disastrous. Homelessness is an added impediment to properly taking medications, following treatment regimens or keeping medical appointments. Managing diabetes is nearly impossible if you rely on soup kitchens for food.

For children (there are 22,000+ children sleeping in homeless shelters tonight in New York City) the dire health consequences are often irreversible. In very young children it often manifests as a negative impact on developmental and physical growth. Studies show children who are homeless often exhibit significant delays in developing gross and fine motor skills as well as social skills.

In older children there's a negative impact on educational and school performance. They experience a higher drop-out rate. One 2009 study documented a drop-out rate for chronically homeless kids of 75 percent. About one-third of homeless children in one study had to repeat at least one grade. Statistically, homeless children suffer chronic illness at a much greater rate than peers.

Homeless kids have an 83 percent chance of having experienced an incident of violence by the age of 12. They are 15 percent more likely to need mental health care as a result of a trauma than other children exposed to violence.

Another study found "homeless people are at greater risk of premature death than other deprived populations defined by conventional measures of socio-economic circumstances". Poverty is highly correlated with poor health outcomes. But even compared to cohorts of equally poor and equally ill people, homeless peoples' health outcomes are significantly worse.

Now New York State has adopted a public policy, albeit a tentative one, to do something about it.

As part of New York's Medicaid reform the Cuomo administration set aside a very modest $75 million of health care funds for supportive housing for people experiencing or at risk of homelessness. In New York City that's already translated into financing for a 12-story affordable and supportive housing project under construction on Boston Road in the Morrisania section of the Bronx.

The state can use millions of Medicaid dollars to house the homeless because one of the criteria for reform is cost containment or reduction, and New York expects to save billions in future avoidable health care spending. The project is small compared to the problem – and to be sure Medicaid resources are already stretched thin – but it's the start of a sound health care cost savings strategy because permanent, stable housing is health care.

Darryl Towns, Commissioner of the New York State's Homes and Community Renewal Agency, said housing the chronically homeless and providing needed supportive services will also "save the state billions of dollars" because health care costs for those unstably housed are among the highest of any health care consumers.

Housing as a form of health care, not just to produce better health outcomes but to reduce tax spending, isn't really much of a risk. A well-respected 2002 study based on New York City populations with severe mental disabilities reported those who were homeless used about $40,451 in public resources a year in contrast to those in permanent or supportive housing who used $24,170 in public resources. That's a cost reduction of $16,281.

We can quibble about the specific dollar amounts, but no one really argues with the essential points. Health care outcomes are far better if people are housed. And it's a good investment because it saves big money.

"The thing we figured out," according to U.S. HUD Secretary Shaun Donovan, "is that it's actually cheaper, not just better for people, but cheaper to solve homelessness than it is to put a band-aid on it. Because at the end of the day it costs, between shelters and emergency rooms and jails, it costs $40,000 a year for a homeless person to be on the streets."

New York City is known for its high intensity public health campaigns, from anti-smoking to nutrition labeling, promotion of physical activity and the attempt to outlaw large sugary drinks. Last December the mayor rightly hailed the achievement when New York's average life expectancy jumped above the national average to 80.9 years. But maybe the next big thing, the biggest potential public health bang for our tax bucks, might be housing the homeless.